Transformative Education
for Health Professionals

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Structural competency, innovation in social determinants of health teaching

Structural competency, innovation in social determinants of health teaching 

I use the WHO conceptual framework on the social determinants of health (CSDG), see below, to introduce health workforce students to health inequities and the social determinants of health, as useful framing exercise to understand the complex problems health workers / health systems are increasingly facing, and present WHO's call for a shift to integrated people centred health services.


Yet I have struggled to find innovative teaching and approaches to cultural and societal values that contextualises them as a structural determinants of health inequity, and illustrates a systems thinking approach in terms of their impact in routine daily practice. Much of the current teaching frames the cultural and societal aspects as / within intermediary determinants of health, emphasizing the cross cultural understandings of individual patients.  

But as the WHO Commission on SDH (CSDH) report noted "arguably the single most significant lesson of the CSDG conceptual framework is that interventions and policies to reduce health inequities must not limit themselves to intermediary determinants, but must include policies specifically crafted to tackle the social mechanisms that systematically produce inequitable distribution of the determinants of health among population groups. To tackle structural, as well as intermediary determinants requires intersectoral policy approaches." 


Structural competency calls for a "new approach to the relationships among race, class, and symptom expression. It bridges research on social determinants of health to clinical interventions, and prepares clinical trainees to act on systemic causes of health inequalities".

Structural competency which "explores a new clinical politics for understanding the relationships among race, class, and symptom expression. In clinical settings, such relationships often fall under the rubric of “cultural competency,” an approach that emphasizes recognition of the divergent sociocultural backgrounds of patients and doctors, and the cultural aspects of patients’ illnesses.

Evolving literature suggests that conditions that appear from a biomedical framework to result from actions or attitudes of culturally distinct groups need also be understood as resulting from the pathologies of social systems."

Our aim must be to educate and train the health and social workforce to promote health equity through action on the social determinants of health. 

Incorporating structural competency in health and social workforce education on SDH would also enable a health in all policies approach and intersectoral action as called for by the WHO Commission on SDH, and contribute to United Nations 2030 Sustainable Development Agenda and the 17 Sustainable Development Goals, particularly SDG 10: Reduce inequality within and among countries.


Author; Julian Fisher, Hannover Medical School, Germany





Structural competency: Theorizing a new medical engagement with stigma and inequality Jonathan M. Metzl and  Helena Hansen

JOURNAL OF BIOETHICAL INQUIRY: STRUCTURAL COMPETENCY SPECIAL ISSUE Structural Competency in the U.S. Healthcare Crisis: Putting Social and Policy Interventions Into Clinical Practice.” Hansen, Helena and Jonathan Metzl. J Bioeth Inq. 2016 May 13.






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